52 years Female
Pain in right upper quadrant for 3 months
USG examination shows multiple calculi in GB and lower CBD
Open cholecystectomy with removal of CBD calculai was performed.

After one week of surgery patient developed off and on Haematemesis & malena.

After 3 weeks of surgery Upper GI scopy was performed small ulcers was found in lower end of oesophagus, sclerotherapy given, Patient is symptom free for 3 weeks.

After 2 weeks of sclerotherapy again patient had haematemesis and malena but this time severity is more with - rapid fall in Hb (11.5 gm % to 5.6) over a period of 1 week.

Again Upper GI scopy was performed but appears normal.

NC & CECT was ordered.

Post-coiling angiogram, pseudoanerysm is not filling.

Follow up of 4 weeks. No symptom of haematemesis and malena. Hb is improved from 5.6 to 8.5 gm %.

"Iatrogenic injuries to hepatic artery system may evolve to pseudoaneurysms in the late postoperative period. Although rare, pseudoaneurysms after open cholecystectomy can occur, are a serious clinical entity and very difficult to detect. We present a case of iatrogenic pseudoaneurysm after cholecystectomy. The onset of symptoms occurred 5 days after an uneventful operation. Endovascular coil embolization for a large pseudoaneurysm was successfully performed."

Review of the literature reveals fifty-four more cholecystectomy-related pseudoaneurysms. The site of injury was the right hepatic artery in 61% of the cases and the presenting symptom was hemobilia in two-third of the patients. Embolization was performed in 82% of the cases and surgery undertaken in the remaining 18%. Knowledge of the condition should result in early diagnosis and thus limit the resultant morbidity. Embolization is the first line of treatment and surgery is reserved for more complex injuries and cases with life-threatening rupture of the aneurysm.

The majority of the cholecystectomies are safe. However, the procedure still carries the risks of biliary, vascular and other complications. The incidence of reported vascular complications has been less than that of biliary complications. Vascular injuries during cholecystectomy can occur in an analogous fashion to biliary injuries with potential laceration, transection and occlusion of blood vessels. They are most frequently represented by intraoperative bleeding during dissection of the Calot's triangle, either from the hepatic artery or the portal vein. Although hepatic artery pseudoaneurysm is an exceedingly rare condition, there are several isolated case reports in the international surgical literature. They can occur in the early or late postoperative course and often pose a considerable diagnostic and therapeutic challenge. The discovery of a pseudoaneurysm of the right hepatic artery, 5 days following open cholecystectomy.

24 year old female primipara was transferred from another institution after delivered an infant At admission according to provided history patient had a blood loss of about 1,000 mL. The hemoglobin level was dropped from 10.5 to 4.48 g/dL. The presence of disseminated intravascular coagulopathy was confirmed with laboratory tests showing thrombocytopenia (platelet count, 43,740/mm, an elevated prothrombin time, and hypofibrinogenemia.

Blood transfusion (3 units) was given because of hypovolemic shock, due to disseminated intravascular coagulopathy, fresh-frozen plasma, fibrinogen and platelet units were administered.

The protocol for treatment was determined by means of consensus among the obstetrician and interventional radiologist available on a 24-hour basis in our institution. Initial evaluation and resuscitation were despite the treatment just mentioned. The potential risks and benefits of the procedure were explained, and informed consent was obtained from the patient or her family.

Digital subtraction angiography was performed by an Interventional radiologist on an emergency basis using a right-sided unifemoral approach. Both internal iliac angiography and selective study of the anterior division were then performed with a 5-F Robert-uterine catheter (Cook) and a hydrophilic polymer-coated 0.035-inch guide wire (Radifocus; Terumo) to analyze the uterine and other arteries of pelvis. Superselective angiography of the uterine and Other anastomotic vessels, such as vaginal branches also studied. Pledgets of absorbable gelatin sponge (Gelfoam) followed by Polyvinyl alcohol dehydrated particles (400-600um diameter) were freely introduced with fluoroscopic guidance.

Postembolization angiography was performed to ensure the complete occlusion of the vessels and patient was transferred to the intensive care unit for further observation and coagulation studies with the arterial femoral introducer left in place until coagulation disorders were corrected.

Angiography showed bleeding from the uterine artery and from a vaginal branch. Bilateral embolization of the uterine artery and right vaginal artery were selectively embolized because of active bleeding. The total procedure lasted for 25-30 minutes. External bleeding disappeared in 30 minutes

Biologic coagulation disorders improved markedly within a few hours. No subsequent transfusion was necessary. Other vital parameter becomes normal within 3 hrs time. No complication was observed during and post embolization. The length of stay in the intensive care unit was 1 day. Women was discharged on the 5th day after embolization.

Primary postpartum hemorrhage is usually controlled with specific medical management or surgical repair in case of vaginal or cervical tears, with curettage, and with vaginal packing.

For patients whose condition continues to deteriorate, ligation of the internal iliac artery or its branches or even hysterectomy is often the favored treatment. Ligation of the internal iliac artery, however, may fail to stop the bleeding in 50% of cases. The reason is that bilateral ligation of the proximal segment of the internal iliac artery reduces blood flow by only 48% and the average pressure by 24%. Surgical ligation is proximal so that collateral yessels can supply blood to the uterus, and the bleeding can recur. Ligation of uterine arteries seems to be efficient in cases of moderate bleeding if it is performed at the time of cesarean section

Hysterectomy of a full-term gravid uterus carries with it a high operative risk and morbidity, including secondary bleeding due to edematous tissues and distorted anatomy. An extrauterine site of bleeding or inadequate arterial ligation may account for failure of hysterectomy to stop the bleeding. Finally, hysterectomy prevents future reproductive function.